Bob Wachter: “Last month on the wards, I unilaterally told two patients’ families that we were not going to resuscitate their loved ones. My residents were horrified ““ this violated the DNR playbook ““ but the alternative seemed both immoral and absurd.”
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{ 5 comments }
I would say that a majority of families who say they want everything done are waiting for “permission” to make a decision the other way. They are actually afraid of what others would think of them if they decide to withhold treatment. It is common practice to ask families “What do you want us to do?” I think that is professionally irresponsible for us not to guide them toward a more sensible pathway. Why not say, “We will do what you would like us to do, but this is what I think would be best for the patient at this time.” Many families want to make the decision to withhold care but need some validation before doing so. Dr. Wachter is perhaps taking this a small step too far, but we should be more proactive in telling families what we think.
why do doctors have such a tendency to blame ourselves for our patients’ and their family’s misunderstanding?
I have the DNR discussion like the above at least weekly, and most people still have unrealistic expectations.
saying “we should be more proactive…” is such crap, & validates the societal mentality that all responsibility should fall on the doctor for everything.
Sorry, anon 5:11, but that’s just my observation. You must have some tough families. What I hear all the time is “What would you do?” So I tell them, and most of them listen. It’s not crap, it’s reality.
I also generally find that people can’t bring themselves to make what they know in their gut is the right decision for a DNR if the doctor just stands their waiting for an answer. They don’t know and can’t learn all the ramifications of that in 10 minutes and most want the doctor’s leadership on that–they just need permission–a thumbs up that this is what he would do were it his family, etc.
I also think that the more paternalistic position of refusing to resucitate people regardless of DNR status in certain situations is appropriate and really no big deal. When I was an intern 20 years ago we were encouraged at one of the hospitals I rotated through to, even at the bedside, make that decision if medically appropriate. It is a medical treatment and the physician shouldn’t provide it if he believes it is inappropriate. Cracking a 90 pound geriatric cancer patients ribs as a necessary ritual of death because the family has death issues is, in my mind, cruel, inhumane and unethical and I refuse to do it.
Our obligation is to the patient, and we are out of line to put them through hell because of the families inability to function in crises.
Kubler Ross wrote about this in 1969. Today’s mned students just aren’t told to read it. People cannot accept the death of their parents. Physicinas need to get better at understanding the roots of these fears (including myslef) and explain them to families. And then we have to get Medicare and insurance companies to PAY for this expert advice, since it does take time.
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